Handbook of Operating Procedures

I. POLICY AND GENERAL STATEMENT

In recognition of tuberculosis as a serious public health threat, The University of Texas Health Science Center at Houston (“University”) adopts the following policy to minimize the risk of exposure of employees, trainees (students, fellows and residents), patients and the general public to infectious tuberculosis. These measures are described in detail in the Tuberculosis Control Plan contained in the Institutional Biosafety Manual and are in line with current Centers for Disease Control and Prevention (“CDC”) recommendations. Healthcare workers are required to become familiar with and to abide by the Tuberculosis Control Plan.

Employees and trainees with latent tuberculosis may attend classes and perform job duties and educational activities as long as they are physically and mentally able to participate and as long as they are able to perform job duties. Employees and trainees with infectious tuberculosis may be denied access to the University's facilities, may have restrictions placed on their job duties, and may be placed on a leave of absence until they are no longer infectious.

Without good cause, no healthcare worker may refuse to treat individuals infected with Mycobacterium tuberculosis or to perform job duties that involve contact with the tuberculosis bacterium. Healthcare workers must seek prior approval from their supervisors if they have good cause for refusing to treat individuals infected with Mycobacterium tuberculosis or to perform job duties that involve contact with the tuberculosis bacterium.

II. DEFINITIONS

Tuberculosis (TB): An infectious disease caused by the bacterium tuberculosis, Mycobacterium tuberculosis, which is transmitted in airborne particles, called droplet nuclei, from a person with infectious tuberculosis and breathed in by a non-infected person who may contract the disease.

Latent tuberculosis (LTBI): The stage of the disease following initial infection when the immune response limits further multiplication and spread of the disease. A person with latent TB is not infectious to others as long as the bacterium remains dormant.

Infectious (active) tuberculosis: The stage of the disease after an individual converts to clinically active infectious pulmonary or laryngeal TB, at which time the infected individual can transmit TB to others by coughing and sometimes by sneezing or talking.

Healthcare worker: Employees, residents, students, postdoctoral research fellows, visitors or anyone working under the auspices of the University who are directly related to provision of healthcare services and have the potential to be exposed to patients and infectious materials.  

Risk assessment: A procedure to evaluate the level of risk of exposure of individuals to airborne TB in a work area based on 1) the type of work performed, 2) the prevalence of TB in the surrounding community and in the particular area of the facility, and 3) the rates of person to person transmission of TB. Risk of exposure, assessed as low, intermediate, or high, determines the frequency by which healthcare workers must be screened for TB. The University's Tuberculosis Control Plan, contained in the Institutional Biosafety Manual, describes the risk assessment procedures.

Exposure to tuberculosis: The possible contact of a non-infected individual with tuberculosis bacilli in airborne droplet nuclei from aerosolized secretions, such as sputum, from persons with infectious pulmonary or laryngeal TB.

Infectious Diseases Review Panel: A subcommittee of the Institutional Biosafety Committee appointed to review instances of infection from communicable diseases in healthcare workers and to determine those circumstances, if any, under which a healthcare worker who is infected with a communicable disease may perform his or her job responsibilities.

Interferon-Gamma Release Assay (IGRA): A type of whole-blood test that can aid in diagnosing TB infection. Examples include the Quantiferon and T-SPOT tests.

Tuberculin Skin Test (TST): A test for TB infection in which tuberculin purified protein derivative (PPD) is injected into the inner surface of the forearm.

III. PROCEDURE

A. Healthcare Workers Tuberculosis Screening Program

Baseline Screening: Healthcare workers will be screened, upon initial employment or admission to educational programs, by the UT Student Health Clinic ("UTSHC") for students and UT Health Services ("UTHS") for employees and residents. The baseline screening process includes testing for TB infection and an individual risk assessment to evaluate if one is at increased risk for infection.

Indicators that an individual is at increased risk for TB:

1. Temporary or permanent residence (for ≥1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe); or
2. Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month), or other immunosuppressive medication; or
3. Close contact with someone who has had infectious TB disease since the last TB test

When TB screening is indicated, healthcare workers are required to participate in the screening process (which in the case of PPD skin testing requires both an initial and follow up visit to be completed successfully).  Failure to participate may result in the healthcare worker being restricted from clinical activities until adequate screening has been completed. Contract employees will, at the employer’s expense, comply with TB screening and surveillance activities.

Additional Screening: In the absence of known exposure or evidence of ongoing TB transmission, healthcare workers without LTBI should not undergo routine serial TB screening or testing at any interval after baseline. Healthcare personnel with LTBI will be assessed by UTSHC or UTHS regarding treatment regimen and further screening on an annual basis.   For personnel/students with increased occupational risk or ongoing exposure to TB, annual TB screening testing will be required.  Additional screening for students may be requested by the UT Student Health Clinic or the individual schools.  Examples of high-risk settings include, but are not limited to, personnel working in the following areas: ICU, Internal medicine, Family Practice, Emergency Medicine, Pediatrics, Surgery, Neurology, and laboratory personnel working with Mycobacterium tuberculosis.

Positive Test for Tuberculosis: Healthcare workers with a positive screening test for TB infection should complete further diagnostic testing, including a chest x-ray, prior to returning to the clinical environment. UTHSC or UTHS will evaluate the clinical data and offer the employee treatment. UTHSC or UTHS will clear the employee to return to work. Tests that come back “borderline” or “indeterminate” will be addressed on a case by case basis, for example:

1. Follow up immediately with a different test (e.g., a PPD/TST instead of an IGRA, or vice versa)
2. If they are asymptomatic, repeat the same IGRA at a future point in time, e.g., 6 months later.

Detailed screening information is found in the Institutional Biosafety Manual, Tuberculosis Exposure Control Plan.

B. High Risk Laboratory Workers Tuberculosis Screening Program

Employees or students who work in high risk laboratory settings, such as labs that work directly with Mycobacterium tuberculosis bacteria or patient samples from known TB positive patients, as well as employees or students who work with or around non-human primates as part of their research or job activities, will be screened for TB as described in Section A above.

C. Management of Positive Tuberculosis Screening Tests or Indications of Infection

All positive TB screening tests will be tracked and monitored by the UTSHC for students and UTHS for employees and residents. Students with a positive TB screening test will be referred to UTSHC or to the provider of their choice for evaluation and management.

Evaluation and management of employees and residents will be referred to UTHS or to the employees’ respective providers of choice. Employees and residents who use UTHS and will not be responsible for the cost of examination, radiographic studies, laboratory studies and medication.

It is the responsibility of the student or employee to provide documentation of non-infectivity to UTSHC or UTHS.  Additional information may be requested after review of this information.

Healthcare workers are required to follow CDC guidelines for the prevention of the spread of TB. It is the responsibility of the appropriate supervisor or attending clinician to monitor compliance with all infection control precautions.

The job duties or educational activities of a healthcare worker with infectious TB may be restricted in accordance with the Tuberculosis Control Plan found in the Institutional Biosafety Manual. The healthcare worker has the right to review any such restrictions and the right to request periodic review by the Infectious Diseases Review Panel. Students should be offered an alternative curriculum if practicable.

Healthcare workers who fail to comply with TB screening requirements, treatment for active TB, infection control measures, or job restrictions and limitations will be subject to disciplinary action.

D. Employee/Student Exposure Procedure

Upon suspected employee or student exposure to TB, the employee or student shall:

1. Notify their clinic supervisor to report the exposure
2. Obtain medical evaluation at UTHS or UTSHC
3. Complete the “Supervisor’s First Report of Injury” to document exposure and submit to Risk Management & Insurance Program at OCB 1.330 or fax to 713-500-8111

Based on a risk assessment by UTHS or UTSHC, review of the exposure incident and previous TST (prior to implementation of IGRA testing) or IGRA results, an action plan for further testing and/or treatment will be outlined. UTHS or UTSHC will screen the employee with an IGRA 8-12 weeks after the date(s) of exposure.

E. Confidentiality

Disclosure of the TB status of an employee trainee, healthcare worker or patient is prohibited except as required or authorized by law.

TB status information in worker’s compensation files will not be released without that individual’s written consent. TB status information will not be placed in an individual’s personnel or student file.

F. Education Efforts

Healthcare workers receive training on measures to prevent exposure to TB initially upon employment and procedures to manage possible exposures to TB as described in the Institutional Biosafety Manual.

IV. CONTACTS

• • UT Health Services (Employee Health)
  • 713-500-3267
  • After Hours Needlestick Hotline: 1-800-770-9206
  • https://uthealthservices.com/
• • UT Student Health & Counseling Services
  • 713-500-5171
  • https://www.uth.edu/studenthealth/
• • University Relations & Equal Opportunity (questions regarding rights in relation to ADA or religious accommodations)
  • 713-500-2255
  • https://www.uth.edu/hr/department/equal-opportunity/
• • Environmental Health & Safety (questions regarding the Tuberculosis Control Plan)
  • 713-500-8100
  • https://www.uth.edu/safety/index.htm
• • Applicable Student Affairs Office (students with questions regarding their rights in relation to tuberculosis infection)

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